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Ic APPLICATION FOR SANITATION PERMIT Permit No. 1--- ----------- w (Complete in Duplicate) Date Issued r r� ` r Applicai on is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor herein describe This apph;ation is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----------- ------�--------------- �----- ---------- �' ✓ .Sra� r - Phone------------------------------------ Owner's Nane------------------------------ --- -------- -------- -- - Address------- --------------------------------------------------- ,------------------------------------------ me / a'�/ ------------ Phone..--------------------------------- Contractor'r Na ---------------------------- - Installation -kill serve: Residence LK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Nur h! . of living units: -------- Number of bedrooms __`rf Number of baths __/___ Lot size --__, p--- ---- --- y ��.� 'tca Water Supply: . Public system ❑ Community system 0 Private,. Depth to Water Table _-�_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay f�` Adobe❑ Hardpan Previous Application Made: Yes [INo F-1New Construction: Yes E] No E] QQ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) op Septic Tank: Distance from nearest well__. f�.F__Distance from foundation__-.f -_1-----.Mater al------ --------------------------- .___- `_��=t-5-�__ -------- No. of compartments.------y--------- --Size...`_ _` � -------Liquid depth-------- - .........Capacity----�`fs-d--�- Di I Field: Distance from nearest well-__- �-_-..-Distance from foundation-------� r---Distance to nearest lot line.--__------ Number of lines------ -a- v-----------------Leng#h of each line------------------------------Width of trench---------/� �I'll----------- a Type of filter material_-/4E -------Depth of filter material.--__f -------------Total length------.._._----.____--- ---_-_ Seepage Pit: Distance to nearest well-----------------------Distance from foundation--------------------Distance to nearest lot line----------------- E-1 Number of pits----------------------Lining material----------------------Size: Diameter-------------- --------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-___-_-__-__-----.____----_-_-- ❑ -----------Depth------------------------------------------------Liquid Capacity---------------------------- als. Size: Diameter r ce w f n;i;773 -----..� ------------- ----- .T..�._. . — Priv istanom f we7l - ------------------ Dis once from nearest building ❑ Distance to nearest lot line--------------------------------------------------------------------- ------------------------------------------------------- Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- - -- -- - - - - - --------------------------I------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----_ (Owner and/or Contractor] �/. •,� J ----- Title---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------- =-- �---------------------------------------------------------- DATE----------- REVIEWED BY ------------- DATE--------------------------- ----------------------------- ---------- -- ---- BUILDING PERMIT ISSUED--------------------------- ------- ----------- DATE Alterations and/or recommendations=---------------------------- ---------------------------•---------•------------------------------------------------ ------------------------------------ ------------------ --------------------------------------------------------------------------------- --------- -------------------------------------- --- --- _ - FINAL INSPECTI - --- Date--- - ..._.. iI!t ----- .. -------------------- SAN JOAQUIN LOCAL HEALTH DI ICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M 8-51 Revised W-2100